FOREIGN BODY IN HEPATIC DUCTS PRODUCING OBSTRUCTIVE JAUNDICE OF SEVEN YEARS' DURATION WITH INTERNAL BILIARY FISTULA*

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1 FOREIGN BODY IN HEPATIC DUCTS PRODUCING OBSTRUCTIVE JAUNDICE OF SEVEN YEARS' DURATION WITH INTERNAL BILIARY FISTULA* BAXTER L. CRAWFORD AND HAROLD L. STEWART From the Pathology Laboratory of the Jefferson Medical College Hospital, Philadelphia Foreign bodies in the biliary passages may gain entrance from the stomach or intestines or at the time of surgical procedures on the biliary tract. The suspected presence of a lesion of this type rarely enters into the differential diagnosis of biliary colic or obstructive jaundice because of its rarity and lack of specific symptoms. A diversified group of objects have been found under these circumstances, such as swabs, thread, bristles, gauze, fruit seeds, cherry stones, steel needles, pieces of wire, handle of spoon, bullets, rubber drains, and absorbable and non-absorbable suture material (Toland 1 and Rollestone and McNee) 2. One of the unusual features in certain cases of biliary tract foreign body is the long duration of the symptoms as illustrated in the case here presented and in a number of the cases reviewed in the literature. REPORT OF A CASE This case was presented before the Philadelphia Pathological Society, November 12, M. S. White female, single, aged 33 years, was admitted to the Jefferson Hospital with marked jaundice. Attacks of jaundice had been recurrent at intervals over a period of 7 years following cholecystectomy and appendectomy. The cholecystectomy had been performed in 1927 for "bilious attacks" associated with nausea, vomiting and severe epigastric pain of one year's duration. Very little could be learned about the details of this operation as it had been performed at a distant hospital. Following inquiry the diagnosis was given as chronic appendicitis and cholecystitis, with appendectomy and cholecystectomy, the condition of the patient on discharge being described as * Received for publication May 2d,

2 354 BAXTER L. CRAWFORD AND HAROLD L. STEWART good. According to the patient's story there was evidently considerable trouble following cholecystectomy. Drainage was continued for seven weeks and a second operation was performed, presumably appendectomy, followed by drainage for four weeks. The entire period of hospitalization was four months. Only three weeks after leaving the hospital, in 1927, she developed painless jaundice accompanied by pruritis, dark urine and clay-colored stools. These symptoms persisted for two or three weeks and then subsided, recurring subse- FIG. 1. X-BAY FILM OF ABDOMEN FOLLOWING INGESTION OF BARIUM The long metallic foreign body is present in the right upper quadrant. quently at fairly regular intervals of about 2 months. During the past three years, the patient bled frequently from the nose and from practically any traumatic lesion however slight. Although some degree of clinical icterus was usually present, even in the intervals between the major attacks, there was no history of abdominal pain at any time since operation. Jaundice became pronounced 6 months prior to the present admission and persisted until death.. Physical examination revealed marked jaundice. The spleen and liver were both palpable below the costal margin on inspiration. There was some tenderness over the upper border of the right rectus muscle but definite rigidity could

3 FOREIGN BODY IN HEPATIC DUCTS 355 not be elicited. Small placques of xanthelasma were observed on the left upper eyelid and along the lateral margins of the nose. Roentgenographic study of the right upper abdominal quadrant disclosed the presence of a long, thin, dense, metallic body, curved slightly to the right and directed anteroposteriorly, the longest measurement of which was estimated at approximately 3.3 cm. (fig. 1). There was a marked degree of secondary anemia. The blood platelets ranged between 254,000 and 346,000. The urine contained a trace of albumen and hyaline and granular casts. The Van den Bergh reaction was positive direct; the serum bilirubin varied between 5.12 mgm. and mgm. per 100 cc. On different occasions, the bromsulphalein retention varied between 40 and 100 per cent at the end of 30 minute periods (2 mgm. dosage). The blood cholesterol was 198. Therapeutic biliary drainage was employed and bile obtained in the drainage in each instance. Other treatment was directed to combat the severe anemia and improve the hepatic function to permit surgical measures for the relief of obstructive jaundice. The patient seemed to improve for a time, but five weeks after admission she began to regress rapidly. There was profuse epistaxis, the blood platelets dropped to 140,000 and the blood coagulation time was 15 minutes and the bleeding time 12 minutes. She vomited large amounts of blood and developed extensive areas of subcutaneous hemorrhage the day preceding death, which occurred Post-mortem examination - The autopsy, which was limited to examination of the abdominal contents, was performed 7 hours post-mortem. The mucous membranes and skin were pale and jaundiced. There was an old healed scar in the right upper, and another one in the lower right quadrant of the abdomen. The peritoneal cavity contained a large amount of dark, bloody fluid and the serosa was everywhere congested. The esophagus, stomach and proximal part of the small intestine were greatly distended with dark, greenish fluid and gas. The pyloric end of the stomach was displaced and attached by many adhesions to the under surface of the liver at the site of the old fossa of the gall bladder. The duodenum was markedly dilated and, just below the pyloric ring, contained a fistulous opening from which bile could be expressed. The mucosa of the ileum was congested in areas and for a distance of 40 cm. In the midportion the entire circumference of the wall and corresponding mesentery was hemorrhagic. Below this point, the remainder of the ileum and the colon contained a large amount of bloody fluid. The liver weighed 2600 grams and measured 27 x 24 x 10 cm. (fig. 2). It was tough, finely granular, irregular in shape and mottled dark green. The right lobe which was large and dome-shaped, was surrounded by many adhesions. On section, a large amount of pale, ropy, light, greenish fluid escaped from the greatly dilated intrahepatic biliary passages. The left hepatic duct averaged 3.5 cm. in diameter practically throughout its entire course. The usual mark-

4 356 BAXTER L. CRAWFORD AND HAROLD L. STEWART ings of the liver substance were replaced by small, pale, yellowish green areas, measuring less than 1 mm. in diameter, which stood out against the dark green of the surrounding tissue. The gall bladder was absent. The common bile duct, which was patulous throughout and somewhat dilated, formed an acute angle near its origin and ran an extended course of 12 cm. emptying into the duodenum at the usual location. The duodenal fistulous FIG. 2. LIVER The surface of the liver is covered with adhesions. The common bile duct (A) terminates in the duodenum at (B). A white probe is inserted into the fistula. To the right of the pole, the foreign body may be seen in the bile duct. tract, mentioned above, admitted a probe of 1 mm. in diameter and opened into the common hepatic duct at what appeared to be the junction point with the common bile duct. The common hepatic and the right hepatic ducts were markedly dilated, the latter measuring 1.5 cm. in diameter. The foreign body was found to be a blade of a hemostat, which measured 4.2 cm. in length, and which occupied the lumen of the common hepatic and first portion of right hepatic ducts (fig. 3). The foreign body was coated over with dark green, friable, pigment concretion. The sharp fractured end of the blade pointed in the direction of the duodenal fistulous opening. The left hepatic duct was considerably dilated above its orifice.

5 FOREIGN BODY IN HEPATIC DUCTS 357 Microscopic description of liver The hepatic parenchyma was divided into small nodules by bands and dense masses of pigmented connective tissue containing necrotic hepatic cells, a few proliferating bile ducts and many foci of inflammatory cells chiefly lymphocytes. FIG. 3. CURVED BLADE OF HEMOSTAT FOUND IN RIGHT AND COMMON HEPATIC DUCTS The portion on the left was covered by the friable calculus lying below. The sharp fractured edge on the right pointed in the direction of the duodenal fistulous opening. There was considerable distortion of the architectural pattern; the hepatic cells were swollen, the cytoplasm granular, and the nuclei poorly stained, and many contained bile pigment. The large intrahepatic branches of the bile ducts were dilated, the epithelial lining cells were necrotic and many had desquamated and the walls of the ducts were thickened and fibrous.

6 358 BAXTER L. CRAWFORD AND HAROLD L. STEWART COMMENT Foreign bodies in the gall bladder are not uncommonly met with usually the result of material such as sutures, sponges, etc. left behind after operation, but foreign bodies found in the bile ducts are very rare except as pathological curiosities. A diagnosis of the presence of a foreign body in the biliary passages was made preoperatively in this case by means of the roentgenological examination. Because of the patient's critical physical condition and lack of improvement, surgical intervention was out of the question. It was obvious at this point that the patient was suffering from hepatic insufficiency, the result of the long standing biliary obstruction. It has been pointed out by others that a foreign body may gain entrance to the biliary tract by migration from the gastrointestinal tract or peritoneal cavity or directly by accidently leaving them in the ducts after operation. However, since in this instance no detailed description of the previous operation could be obtained, it is impossible to throw any light on the mode of entrance of the foreign body into the biliary passages. If the nature of the obstruction had been recognized earlier before the damage to the liver was so great, it could no doubt readily have been corrected by surgical intervention. The periodical attacks of jaundice and the clinical manifestations during the last 7 years of the patient's life, were similar to those produced by stone in the common bile duct. The complete absence of pain in these attacks, however, is a notable feature. The foreign body was situated within the right and common hepatic ducts, in which the formation of gall stones is rarely_ demonstrable. It acted as a nucleus for the incrustation of bile salts and pigment which were deposited irregularly on the surface increasing the thickness of the object several times. Whether or not the amount of calculous deposit on the foreign body played any part in the symptoms of obstruction is difficult to say but was suggestive. It is interesting that the wire in Cooke's 3 case and the drainage tube in Federoff's 4 case had undergone no appreciable change although the latter object had been resident in the common bile duct for 5 years. Calculous formation has been observed in

7 FOREIGN BODY IN HEPATIC DUCTS 359 association with suture material in the biliary passages in several instances, with cotton in the common bile duct (Toland) and with a gauze sponge which remained in the gall bladder for 11 years (Bevan) 6. The effects on the liver of the recurring attacks of biliary obstruction resulted in chronic hepatitis, with pigmentation, marked fibrosis and destruction of the lobular pattern to an extent rarely observed, except in the liver of portal cirrhosis. As with stone in the common bile duct, the intermittance and degree of obstruction, the number and duration of the obstructive periods, the length of sojourn of the foreign body in the bile ducts, coupled with the presence of infection, combined to produce hepatic lesions of a marked grade of severity. The development of the duodenal fistula in this case did not obviate the effects of biliary stasis, since the communication was established at a point below that at which impaction in the bile ducts were occurring. Aside from alleviating the effects of any obstruction which might have resulted from the marked angulation of the common bile duct, the only possible consequence of the fistulous tract was to permit regurgitation of duodenal contents into the bile ducts. Although no evidence was obtained roentgenographically that this occurred to any extent following ingestion of barium, it is a logical assumption in view of the dilatation and marked obstruction of the duodenum by adhesions, which were demonstrated postmortem. CONCLUSIONS A case is reported of obstructive jaundice of 7 years duration due to a calculous encrusted foreign body (blade of hemostat) in the hepatic ducts, with a duodenal fistulous communication. The manner in which the foreign body gained access to the biliary passages could not be determined. REFERENCES (1) TOLAND, C. G.: Foreign bodies in the biliary tract. Annals of Surgery, 98, , (2) RALLESTON, H., AND MCNEE, G. W.: Disease of the Liver, Gallbladder and Bile Ducts. 3rd Ed. 1929, 578, 764.

8 360 BAXTER L. CRAWFORD AND HAROLD L. STEWART (3) COOKE, R. G.: Foreign body in the common bile duct. British Medical Journal, 1, 840, (4) FEDOHOFF, S. P.: Drainrohr im Choledochus 5 Jahre lang. Zentralhl f. Chir., 57, , (5) BEVAN, A. D.: Gauze sponge left in gallbladder; removal after interval of eleven years. Surgical Clin., Chicago, 4, 31-35, 1920.